Provider Demographics
NPI:1164515037
Name:GRANT, PAMELA JILL (RN, MSN, CS)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JILL
Last Name:GRANT
Suffix:
Gender:F
Credentials:RN, MSN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 101ST ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-4045
Mailing Address - Country:US
Mailing Address - Phone:806-786-4378
Mailing Address - Fax:
Practice Address - Street 1:3301 101ST ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-4045
Practice Address - Country:US
Practice Address - Phone:806-786-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX511760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX062534501Medicaid
TX062534501Medicaid
TXCN0046Medicare ID - Type Unspecified